CY 2019 Free Clinic Program application markup 06_22_18

APPENDIX A

FREE CLINIC FTCA PROGRAM APPLICATION

The following tables provide the information that will be collected in the initial, redeeming and supplemental deeming application through EHB:

Section I. Contact Information*
Executive Director First Name: Last Name: E-mail: Phone Number: Fax Number:
Medical Director First Name: Last Name: E-mail: Phone Number: Fax Number:
Risk Management Coordinator First Name: Last Name: E-mail: Phone Number: Fax Number:
FTCA Contact First Name: Last Name: E-mail: Phone Number: Fax Number:
*Send state documentation indicating legal name change if legal name change occurred since last deeming application.

Section II. Site Information
Name: Address: Phone Number: Fax Number: E-mail: Site Type: Days/Hours of Operations:
*All free clinic sites must be listed. Each site must be appropriately identified as the main site or as an additional site.

Section III. Sponsoring Free Clinic Eligibility

1. The sponsoring free clinic is a registered nonprofit organization. (Please attach documentation if an Initial Applicant)

[ ] Yes

2. The sponsoring free clinic and its sponsored individuals comply with the definitions relative to covered individuals as set forth in PIN 2018-0X.

[ ] Yes

3. The free clinic does not accept reimbursement from any third-party payor (including but not limited to reimbursement from an insurance policy, health plan, or other Federal or State health benefits program).

[ ] Yes

4. The free clinic does not impose charges on patients either based on service provided or the ability to pay. (The free clinic may accept only voluntary donations from patients and other third parties.)

[ ] Yes

5. The free clinic is licensed or certified in accordance with applicable law regarding the provision of health services.

[ ] Yes

[ ] No (If no, then explain)

6. The free clinic and/or individual health care professional provides a patient a written notification explaining that the patients’ legal liability is limited pursuant to the Public Health Service Act.

[ ] Yes

[ ] No (If no, then explain)

Section IV. Credentialing and Privileging Systems*

1. The free clinic periodically verifies licensure, certification and/or registration of each volunteer health care professional according to the instructions in this PIN 2018-0X. (Please remember all volunteer health professionals must be licensed or certified to be eligible for deeming.)

[ ] Yes

2. The free clinic has a copy of each volunteer health care professional’s current license, certification, and/or registration on file at the free clinic for each licensed and/or certified individual. (Please remember all volunteer health professionals must be licensed or certified to be eligible for deeming.)

[ ] Yes

3. If the free clinic uses a hospital to serve as a Credentialing Verification Organization (CVO), there is a written contractual agreement stating the specifics of the expected CVO services.

[ ] Yes

[ ] N/A

4. The free clinic utilizes peer review activities when it privileges each licensed and/or certified individual according to the instructions in PIN 2018-0X.

[ ] Yes

5. The free clinic has a copy of the hospital privileges for each licensed and/or certified individual, when applicable, on file.

[ ] Yes

6. The free clinic annually reviews any history of prior and current medical malpractice claims for each individual for whom deeming is sought.

[ ] Yes

7. A National Practitioner Data Bank (NPDB) query is obtained and evaluated on a recurring basis (for example, every two years) for each licensed and/or certified individual according to the instructions in PIN 2018-0X. Note: do NOT submit a copy of the NPDB report for any individual to HRSA.

[ ] Yes

8. Name and contact information of the Person and Organization conducting credentialing/privileging.

Enter the name and contact information in the Comments section of this question.

*Required for Initial and Redeeming applications. Required for Supplemental applications if the free clinic has changed its credentialing and privileging system since the annual deeming application.

Section V. Risk Management Systems*

1. The free clinic has policies and procedures in place for the provision of appropriate supervision and back-up of clinical staff.

[ ] Yes

[ ] No (If no, then explain)

2. The free clinic maintains a medical record for those receiving care from its organization.

[ ] Yes

[ ] No (If no, then explain)

3. The free clinic has policies and procedures that address:

1. Triage [ ] Yes [ ] No

2. Walk-in patients [ ] Yes [ ] No

3. Telephone triage [ ] Yes [ ] No

If answered No for any of the above, then explain.

4. The free clinic has protocols that identify appropriate treatment and diagnostic procedures based on current standards of care.

[ ] Yes

[ ] No (If no, then explain)

5. The free clinic has a tracking system for patients who miss appointments or require follow-up of referrals, hospitalization, x-rays, or laboratory results.

[ ] Yes

[ ] No (If no, then explain)

6. The free clinic periodically reviews patients’ medical records to determine quality, completeness, and legibility of written entries.

[ ] Yes

[ ] No (If no, then explain)

7. The free clinic has a written, current QI/QA plan that clearly addresses the clinic’s credentialing and privileging process and has been signed by a board authorized representative on a recurring basis (for example, every three (3) years) (please attach a copy of the plan with board approval date).

[ ] Yes

[ ] No (If no, then explain)

8. The free clinic has regular, periodic meetings to review and assess quality assurance issues.

[ ] Yes (If yes, briefly describe the structure (e.g. frequency of meetings, individuals required to attend, etc.) of the committee that meets periodically to review and assess quality assurance issues.

[ ] No (If no, then explain)

9. The free clinic considers findings from its peer review activities when reviewing and/or revising its QI/QA plan.

[ ] Yes (If yes, what information and process is utilized by the clinic when updating and revising the QI/QA plan.)

[ ] No (If no, then explain)

10. The free clinic utilizes quality assurance findings to modify policies to improve patient care.

[ ] Yes

[ ] No (If no, then explain)

11. The free clinic’s volunteer health care professionals annually participate in risk management continuing education activities.

[ ] Yes (If yes, briefly describe the annual risk management educational activities that are available to health professionals.)

[ ] No (If no, then explain)

*Required for Initial and Redeeming applications. Required for Supplemental applications if the free clinic has changed its QI/QA Plan since the last renewal deeming application.

Section VI. Free Clinic Individuals (Volunteer Health Care Professionals, Board Members, Officers, Employees, and Individual Contractors)*
Add Individual Details Prefix: First Name: Middle Name: Last Name: Professional Designation:
Contact Information Email Address: Phone Number: Fax Number: Mailing Address:
Roles and Specialty Role(s) in Free Clinic: Specialty: Others:
Credentialing and Privileging Date of Licensure/Certification Is Licensure/Certification currently active? Yes/No. If No, please stop here. Date of Last Credentialing: Date of Last Privileging: [Please remember that all state licensed and/or certified health professionals need to be credentialed and privileged on a recurring basis (for example, every two years). Not mandatory for ‘Board Members’ and ‘Executive’ role.]
Individual Type: [ ] New Applicant [ ] Renewal Applicant Please select the status of the individual from the options below: [ ] Employee [ ] Licensed or certified [ ] Non-licensed or non-certified [ ] Officer/Governing Board Member [ ] Individual Contractor [ ] Licensed or certified [ ] Non-licensed or non-certified [ ] Licensed or Certified Health Professional Volunteer [Please note that volunteers who are not performing healthcare related functions and who are not licensed or certified to perform such functions are not eligible for the Free Clinics FTCA Program and should not be added to the application.] Please upload primary source verification of current licensure and/or certification. (upload attachment)
Medical Malpractice Yes No N/A
Enter Your Comments Comments: (Comments and an attachment with an explanation of each medical malpractice claim or disciplinary action are required for individuals with Medical Malpractice Claims. Do NOT submit an NPDB report for any individual.)
*Notes: Provide a list of ALL free clinic volunteer health professionals, board members, officers, employees, and individual contractors on whose behalf the free clinic is submitting an application for FTCA deemed status. Please note that free clinic volunteer health professionals must be licensed and/or certified by state or federal law to perform the services that are requested. Provide a physical address for ALL individuals on whose behalf the free clinic is submitting an application for FTCA deemed status. Physical addresses and phone numbers provided for individuals must be personal mailing addresses and phone numbers that are different than that of the clinic. Specify the person’s role in the free clinic for any individual the free clinic is sponsoring for FTCA deemed status. For each individual sponsored for deeming, disclose past medical malpractice claims or disciplinary actions for the past ten (10) years if submitting an initial or supplemental application or for the past five (5) years for redeeming applicants. Attach an explanation of each medical malpractice claim or disciplinary action (to include probationary actions) including explanations of the suit or allegation, medical specialty involved, and a brief statement of whether the clinic implemented appropriate risk management actions as needed in response to allegations to reduce the risk of future malpractice and future such claims. Documentation related to a disciplinary action must include: nature and reason for the disciplinary action; timeframe (where applicable); documentation from the appropriate professional board that states the individual is in good standing and/or a description of any practice restrictions on the licensee. Do NOT submit an NPDB report for any individual.

Section VII. Patient Visit Data*
1. Total number of FTCA deemed individuals, in the recently closed calendar year:
2. Total number of FTCA deemed providers, in the recently closed calendar year:
3. Total number of patient visits conducted by FTCA deemed individuals, in the recently closed calendar year:
*Only required for the annual redeeming application.

Section VIII. Attachments

Attachment A. Non Profit Documentation (Maximum 5)

Required for Initial applications only.

Attachment B. Copy of Clinic’s QI/QA Plan (Maximum 5)

Attach the free clinic’s QI/QA Plan that has been approved, signed, and dated by a board authorized representative on a recurring basis (for example, every three (3) years):

• Required for Initial and Redeeming applications.

• Required for Supplemental applications if the free clinic has changed its QI/QA Plan since the last renewal deeming application.

Attachment C. Medical Malpractice Claims and Disciplinary Actions

Attach an explanation of each medical malpractice claim or disciplinary action (to include probationary actions) including explanations of the suit or allegation, medical specialty involved, and a brief statement of whether the clinic implemented appropriate risk management actions as needed in response to allegations to reduce the risk of future malpractice and future such claims. Documentation related to a disciplinary action must include: nature and reason for the disciplinary action; timeframe (where applicable); and documentation from the appropriate professional board that states the individual is in good standing and/or a description of any practice restrictions on the licensee. Do not submit an NPDB report for any individual.

Attachment D. Other supporting Documentation (Maximum 5)

Please attach any other supporting documentation.

Section IX. Remarks

Is the coverage requested for an offsite event?

[ ] Yes (Enter descriptive information about the offsite events. Please enter the type of service provided and location of the event. A HRSA representative will review this information and will contact the free clinic’s FTCA contact by phone or email to discuss the possibility of FTCA coverage for an offsite event. Please note that approval for individuals for FTCA deemed status at the free clinic’s site(s) does not guarantee approval for FTCA coverage at the proposed offsite event.)

[ ] No

Record Remarks

If yes to the above question on an offsite event, enter descriptive information here.

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[ ] Yes

[ ] No

Section X. Signatures

Certification and Signature

I, ______________ (Executive Director)*, certify that this sponsoring free clinic meets the definition of a free clinic found in Section III of HRSA/BPHC PIN 2018-0X and that the information in this application and the related attachments is complete and accurate.

*The application must be signed by the Executive Director, as indicated Section I. Contact Information.